PROFESSIONALISM A Brief Analysis of Trends in Prehospital Care Services and a Vision for the Future Article No. 990082 Mark S. Chilton Head, Academic Services Monash University Centre for Ambulance and Paramedic Studies Introduction William Roush describes an Emergency Medical Service (EMS) system (ambulance service) as consisting of a communications mechanism to initiate a response, a vehicle with personnel to provide treatment and transport, and a receiving facility to take the patient to. 1 This definition is one that may be largely valid today but may not be so in the future. Current influences on ambulance services as systems, and the role of the ambulance paramedic as a practitioner, are likely to result in a modification of this definition in this country in the future, based on the concept of the public health model. One such example is the provision of care without transport, or referral to an alternative primary care provider. This paper discusses the application of a framework for identifying and examining these influences. The ambulance paramedic as a civilian vocation is still in its relative infancy, being arguably little more than one hundred years old in Australia and the USA for example. 2, 3 As a profession, by most definitions, it is even younger, arguably only just now beginning to be recognised as having professional status within the health care sector in this country. Further, the ambulance paramedic as a professional is more advanced in many respects in this country than many other centres, particularly in terms of its practitioner s educational underpinnings. The move to seeking professional status was recently manifest in the change of name of the Australian industry representative body from the Institute of Ambulance Officers to the Australian College of Ambulance Professionals. The ambulance service as an organisation and as a profession, is also undergoing a period of significant change, which commenced over thirty years ago and continues, with increasing momentum, today. This change has been particularly evident in the organisational, logistical and clinical practice areas. Victoria provides a good example of this period of change. Significant examples include the transition, over time, from seventeen ambulance services serving the State, to two, and the outsourcing of the call-taking/dispatch functions and nonemergency patient transport. And also the significant increase in the range of clinical interventions that have been included in the scope of practice of the ambulance paramedic, in particular the introduction of the Mobile Intensive Care Ambulance (MICA) and Advanced Life Support (ALS). It is important to consider this period of change in the context of an increasingly rapidly evolving public health sector. This evolution is taking place throughout
the entire spectrum of health care, from a systems or organisational to an individual provider level. There have been many influences driving these changes in the provision of ambulance services as outlined in the framework (refer Figure 1). But we are now at a time in our development as a profession where we need to critically evaluate our role in the community. We are at a pivotal point at which we need to develop a vision of the role of the ambulance service and that of the ambulance paramedic in the future. Although there are many differences between the prehospital emergency care systems in the USA and Australia, the need to undertake a critical appraisal and develop a vision or visions for the future is something that was recognised in the USA at least as early as 1996. This is demonstrated by the National Highway Traffic Safety Administration document Emergency Medical Services Agenda for the Future. 1 Although many of the conditions which exist in the USA differ significantly from those in Australia in regard to the provisions of out-of-facility emergency medical services, or ambulance services as they are known in this country, the ambulance services in Australia should look to the leadership provided by the USA in this instance and project a vision for ourselves into our own future. Discussion Evolution of Trends Many factors have influenced past and current trends in prehospital emergency care. The Framework developed in this paper assists in the analysis of the evolution of these trends by providing the current core system elements necessary to operate a contemporary ambulance service (based on the Australian model). These elements are intended to encompass all of the essential activities and underpinnings necessary for the operation of an ambulance service early this century and beyond. The subsequent six categories, which feed into the hub of the framework, incorporate the major events and issues that have significant influence on the current position of the profession. These are, therefore, the issues that need to be considered in planning for the future of the ambulance profession. The relative influence of a given issue or perspective, and their interrelationships, has and will change from time to time, and additional new issues will inevitably emerge in the future. A brief description of these issues is provided. Current core system issues These are the issues that exist today that relate to the potential for a change in the scope of practice of the ambulance paramedic, and include a role in the provision of a triage and referral service and generally a broader role in the public health arena. These issues relate closely with the next two categories in particular. Patient-care issues A wide range of patient care issues are influencing ambulance paramedic practice both in terms of the system and the individual practitioner. Of particular note are the aging population and the continuing trend towards early discharge from hospital and home-based care. Also of note is the move towards health promotion and injury/illness prevention that began to develop significant impetus over a decade ago. The following quote from EMS Agenda for the Future encapsulates this trend: The health system of today, with its emphasis on advanced technology and costly acute interventions to promote societal health, is transitioning to focus on the early identification and modification of risk factors before injury or illness strikes. This transition will lead to a
more cost-effective medical management system and improved patient outcomes. EMS will mirror and, in many cases, lead this transition. 4 The ambulance profession has the potential to be involved to a significant degree in injury/illness prevention and health promotion, and develop a much higher profile, such as that of the fire service in regard to fire prevention. Collaborative research and public education between Victorian ambulance services and the Monash University Accident Research Centre, is just one example of how the profile could be increased. Integration issues Primary health care refers to that care which is given when the patient first seeks help. 5 The ambulance paramedic is, therefore, a primary health care provider. It is essential that we be cognisant of the fact that ambulance paramedics are by no means the sole providers of primary health care nor, indeed, of prehospital emergency care. Further, that the future clearly lies in working closely with the wide range of other providers of primary health care to ensure both the best available care in a given circumstance and continuity of care. The Queensland emergency Medical System Strategic Plan identifies that for the [EMS] system to function effectively, integration, coordination and co-operation needs to be expanded to incorporate all components that comprise the emergency medical system 6. I would take this a step further and suggest that collaboration needs to extend to all members of the health care system, but more particularly to providers of the many primary and/or prehospital health care and services. Historical perspective It is important to be mindful of our origins and learn from the mistakes of the past. We need also recognise that the ambulance paramedic is a relatively young profession and has a great deal of growth ahead of it before it is able to claim maturity. Much of this growth will emerge from future evidence-based research and systems evaluation. It is well recognised that there is currently paucity of information relating the efficacy of ambulance paramedic interventions, and that this needs to be addressed. Societal issues At a macro level it is society that has potentially the greatest say in the determination of the future of the profession. It is the societal values, ostensibly reflected in the policies of governments that to a large extent dictate the place of ambulance services in the greater scheme of things. We need also be mindful of the influence that other stakeholder groups and individuals have at times on the policies of governments that impact upon the role and function of ambulance services. Additional considerations Additional considerations include medical and technological advances that impact at both a system and individual practitioner level, the increasing importance being placed (although not always reflected in practice) on evidenced based medicine, and the role of the media in influencing community perceptions and expectations. Also, far from being of least importance, are the views and attitudes of the ambulance paramedics themselves. None of the issues briefly described above can be viewed in isolation, one from the other. They are all interrelated, and a small change in direction in regard to any one influence may produce a cascade of effect.
GLOBAL HEALTH CARE SYSTEM ISSUES Primary Health Care Health Care Systems Co-responders (Multiple providers GPs, RNs, First Responders, First Aiders, Physiotherapists, sports trainers etc. and other possible future practitioners, i.e. Independent Nurse Practitioners, Physician Assistants etc.) Emergency Services Hospitals Industry/Corporations Continuity of Care PATIENT CARE ISSUES Changing Injury/Illness Patterns Aging Population Out of Hospital Care (e.g. early discharge, day surgery, hospital in the home, Mental Health Act) Clinical Problems Demography Epidemiology Injury/Illness Prevention HISTORICAL PERSPECTIVE Charitable Organisations Individual Initiatives Government Intervention Community Expectations Key Milestones CURRENT CORE SYSTEM ELEMENTS Legislation/Regulations Funding Models (Purchaser/provider) Organisation (Including: finance/human resources/information systems/support services etc) Communications Medical Direction Clinical Care Standards Transports Education & Training Audit & Evaluation Research Planning for the Future CURRENT CORE SYSTEM ISSUES Public Education Public Health Triage Service Changing Scope of Practice (Treatment without transport) Clinical Governance SOCIETAL ISSUES Changing Community Awareness and Expectations Changing Social Mores Changing Societal Moral/Ethical Views Consumer Choice Equity of Access Government Policies Stakeholder Inputs PROFESSIONAL ISSUES General Technological Advances Specific Medical Advances Evidence Based Practice Health Call Centres Role of the Coroner Publicity/Media Staff Expectations Figure 1: Framework for Analysing Trends in Prehospital Care Services
Conclusion A Vision for the Future Ambulance services in Australia have as their core function the provision of prehospital or out-of-facility emergency patient care and transport (including major incidents). Australian ambulance services also provide, to varying degrees, non-emergency patient care and transport. Generally, this is the limit of the major scope of practice; exceptions include the provision of public education in first aid, the provision of primary care at major events and (in the case of Queensland) the hire of baby capsules. Australian ambulance services as a group also struggle to define their place in the context of health care provider versus emergency service. This is evident at a State government level with some ambulance services being under the umbrella of emergency services and others (the majority) health. Although most would agree that their primary task is the provision of health care. As I see it we have fundamentally two choices as a profession. We can continue to focus on our core business the provision of out-of-facility emergency care and transport in relative isolation, including taking those steps necessary to improve this core business. On the face of it, this would seem to be both a reasonable and honourable path to take. Alternatively, we can proactively engage in establishing a closer relationship with other health care agencies, particularly those involved in primary and/or out-of-facility health care, and provide a more integrated service to the community, with an enhanced continuity of care. The latter is more likely to lead to an increase in the scope of practice for the ambulance paramedic, whilst at the same time being of greater benefit to the community. The notion of working in relative isolation and improving our core business may well be contradictory. We need to collaborate extensively with others in areas such as research, information systems and the provision of the best available service to a given patient with a given need at a given time and place. Areas in which an increase in the scope of practice may occur include injury/illness prevention, the provision of patient care and referral without transport, particularly in the rural setting, and the provision of an after-hours paramedical locum service. The ambulance service is well placed in the out-of-facility and out-of-hours environments and should be readily able to adapt these system attributes to enhance its contribution to health care and public safety. The Framework provides an overview of the issues that impact upon the profession. It is incumbent upon us to acknowledge those influences and work with them in guiding our future. If we are hesitant in being proactive and playing a significant role in determining our own future, there is no doubt that our political masters, key stakeholders, and the community in general will determine it for us. Some may argue that in a pluralistic and democratic society, this is as it should be. But ambulance paramedics are also major stakeholders, with unique insights, and have an obligation to provide guidance and direction for the future.
References 1. Roush WR. Principles of EMS Systems. Chapter Two Emergency Medical Service Systems. PAR3020 Course Notes. P12 2. Wilde S. From Driver to Paramedic. A History of the Training of Ambulance Officers in Victoria. AOTC, 1999: Ch 2. 3. National Highway Traffic Safety Administration. Emergency Medical Services. Agenda for the Future. NHTSA, 1996: P6 & P53. 4. National Highway Traffic Safety Administration. Emergency Medical Services. Agenda for the Future. Emergency Medical Service Attributes. NHTSA, 1996: P7. 5. PAR3020 Course Notes, 2004. 6. Queensland Emergency Medical System Advisory Committee. Queensland Emergency Medical System. Strategic Plan 1999 to 2002. 1999, P12. 7. The Convention of Ambulance Authorities. Ambulance Services Australia Report 1998/1999. CAA, 1999: P19. Additional Readings Davies P. Making Sense of Integrated Care in New Zealand. Australian Health Review, 1999, 22(4):25-44. Murray C & Jolley G. Initiatives in Primary Health Care: Evaluation of a South Australian Program. Australian Health Review, 2000, 23(1): 155-161. National Health Service. Clinical Governance: in the New NHS. NHS, London 1999. National Highway Traffic Safety Administration. Emergency Medical Services. Agenda for the Future. NHTSA, 1996. Pencheon D et al. So Many Unanswered Questions: The Emergency Care System of the Future. J Accid Emerg Med, 1988, 15:49-53 Shiell A & Carter R. Public Health: Some Economic Perspectives. In: Mooney G & Scotton R [Eds]. Economics and Australian Health Policy. Allen & Unwin, 1999. The Convention of Ambulance Authorities. Ambulance Services Australia Report 1998/1999. CAA, 1999. Author: Chilton, Mark